| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
231 |
152 |
$112K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
555 |
548 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
331 |
328 |
$19K |
| D2950 |
|
219 |
146 |
$19K |
| D1110 |
Prophylaxis - adult |
270 |
270 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
85 |
42 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
76 |
36 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
466 |
427 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
45 |
24 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
101 |
100 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
93 |
93 |
$3K |
| D0330 |
Panoramic radiographic image |
60 |
60 |
$3K |
| D4341 |
|
31 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
84 |
84 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
142 |
139 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
32 |
$772.54 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$348.88 |